Telemedicine Informed Consent

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. Potential benefits of telehealth (which are not guaranteed or assured) include access to medical care without traveling, more efficient medical evaluation and management, and during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location. Potential risks of telehealth include the inability to conduct a hands-on physical examination, delays in evaluation due to technical difficulties or interruptions, unauthorized access to information, or loss of information due to technical failures. I will not hold REOH responsible for lost information due to technological failures.

By signing this form, I understand the following:

I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
I understand that I will not by physically in the same room as the REOH physician.
I understand that the REOH physician is licensed in the state of Montana and will be in Montana during my telemedicine appointment.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
If it is determined that the videoconferencing equipment and /or connection is not adequate, I understand that the REOH physician or I may discontinue the telemedicine visit and make other arrangements to continue the appointment.
I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record.
I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
I understand that I may be physically examined by a third party as part of this evaluation.
I understand that this document will become part of my medical record.

Please review the “What is an IME” and HIPAA forms and continue filling out this consent form. If you have any questions regarding this form please email Leah at lcm@reoh.com.

What is an independent medical evaluation?

HIPAA Notice of Privacy Practices

Name of person signing consent

First Name

Last Name

Relationship to Evaluee if unable to sign

First Name

Last Name

By signing this agreement electronically I am acknowledging that I, the above listed Evaluee, have personally read all of these forms (or had them explained to me) and fully understand and agree to their contents; have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me; and am located in the state of Montana and will be in Montana during my telemedicine visit(s). By signing this agreement, I understand that I am acknowledging:

I have read and understood the Telemedicine Informed Consent Form

I have read and understood the HIPAA Notice of Privacy Practices

I have read and understood the What is an IME Form

I have access to a device with a microphone and camera

Today's Date

MM

DD

YYYY

I give my permission for this evaluation to be recorded.

Agree

Disagree

* Denotes a required field. This form must be signed and submitted one week in advance of your appointment in order for the evaluation to take place. You must check all four boxes above to electronically sign and submit the form.